Please select one or any of these Cybertech+ Liability Protection coverages

Transcription

1 TECHNOLOGY RENEWAL APPLICATION IMPORTANT NOTES: This Application is submitted to Travelers Insurance Company of Canada ( TICC ) and St. Paul Fire and Marine Insurance Company ( SPFM ). In the event a policy of insurance is issued by TICC, any references to SPFM shall be inapplicable. In the event a policy is issued by SPFM, then (i) any references to TICC shall be inapplicable, and (ii) for purpose of the Insurance Companies Act (Canada), this document is issued in the course of SPFM s insurance business in Canada. Please attach copies of your standard contracts and agreements, most current audited or annual financial statements, and any other information that will better help us analyze and price your insurance coverage. The information provided in this Application is the basis upon which a policy may be subsequently issued. All information provided in this Application forms part of any policy effected pursuant to completion of such section. Please complete all questions. Indicate N/A if a question is not applicable. If additional space is needed to properly address certain questions, please use the Additional Comments at the end of this Application or attach additional sheets on your company letterhead with the details. Throughout this Application, you or your means the Applicant identified in all parts of the Application. PART I: GENERAL INFORMATION The following questions apply to all coverages requested. SECTION A: GENERAL INFORMATION 1. Insured Name: 2. Mailing Address of First Named Insured (including postal code): 3. Please list all mergers, acquisitions, or divestitures within the past year, including dates and whether you acquired or retained assets, liabilities or both for each transaction. 4. Did your due diligence include the following: Review of prior and pending litigation? Evaluation of all outstanding contracts or service agreements to be included as part of transaction? Analysis of Intellectual Property Rights, including any 3 rd party interest in or liens on these rights? SECTION B: COVERAGE REQUESTED 1. Commercial General Liability: Limit Requested: Deductible Requested: 2. Coverage Requested: Please select one or any of these Cybertech+ Liability Protection coverages Technology Errors and Omissions Liability Protection Network and Information Security Liability Protection Communications and Media Liability Protection Limit of Coverage Requested: Deductible Requested: SECTION C: COMPLAINTS, CLAIMS OR SUITS 1. Within the past twelve (12) months, have you ever received any complaint concerning the products or services provided by you or independent contractors working on your behalf? If, please provide details of the complaint, including how your company responds to these types of complaints: TECH006 (02-13) Page 1 of 5

2 2. Within the past twelve (12) months, have you received a complaint concerning the content of your website or customer website (including bulletin boards or chatrooms), , or internet service pertaining to: Disparagement, libel or slander Infringement of copyright, title, slogan, trademark, trade name, trade dress, service mark or service name Unauthorized use of advertising material, slogan or title of others Plagiarism or unauthorized use of material of others Failure to protect the private or confidential information of others Failure to prevent transmission of a computer virus Failure to provide access to any third party. If, to any of the above, please provide details of the complaint, including how your company responds to these types of complaints: 3. Within the past twelve (12) months, have you sued any customers for non-payment of fees? If, please provide details: SECTION D: REVENUES *Revenue means the gross income of a nonprofit or for-profit entity. Examples of revenue include sources such as: sales, receipts, fees, commissions; donations, contributions, dues, grants received by nonprofit and membership organizations; and any other type of income of nonprofit or for-profit entities. Revenue does not include investment income, intra-entity revenue, and returns from overpayment of taxes. Source(s) of Revenue* Current Annual Revenue as of Projected Annual Revenue MM/YYYY Total Canadian Revenue $ $ Total U.S. Revenue $ $ Total Foreign Revenue $ $ Total Revenue $ $ 1. Please list the countries which account for your foreign revenue and the percentage breakdown of income derived from each: 2. Employee Information: # of Employees Current Payroll Canadian Employees: $ U.S. Employees: $ List countries which account for your foreign employees Foreign Employees: $ SECTION E: YOUR TECHNOLOGY BUSINESS ACTIVITIES 1. Please provide the current percentage of revenues for all activities that apply: Application Service Provider (ASP): % Retail Sales of hardware and/or software: % Contract Programming: % Sales of pre-packaged software of others: % Consulting/training: % Systems consulting, analysis and design: % Custom Software Development: % Systems security software, hardware or services: % Data processing Services: Including maintenance, support and Telecommunications products or services: % warehousing % Value added resale and distribution: % Disaster Recovery Services: % Web Site Administration/Website Hosting: % ERP, CRM, Supply Chain or similar software and services: % Web Site Developer: % Hardware Sales or Services: % Wholesale, distribution or manufacturers representatives: % Integration Services: % Please provide description of products: % Internet Service Provider or Online Service Provider: % Manufacturing of hardware, software or related products: % Other: % Pre-packaged software development: % TECH006 (02-13) Page 2 of 5

3 2. Has there been any material change over the past year to the principal market(s) for your product or services? 3. What new products or services are to be released within the next twelve (12) month period? 4. Do you anticipate any changes to your business activities within the next two (2) years? 5. Have any products, services or operations been discontinued or recalled within past twelve (12) months? in detail which products/services were discontinued or recalled, including procedures for informing customers: PART II: TECHNOLOGY ERRORS AND OMISSIONS LIABILITY IMPORTANT NOTE: Technology Errors and Omissions is provided on a claims-made and reported basis. Where legal and applicable, defence expenses are included within the limits of coverage. 1. Please provide details of the three (3) largest contracts, projects or licensing agreements: Customer Type/Name Length of Contract (months) Project/Services/ Products Provided Revenue 1. $ 2. $ 3. $ 2. Do you require written contracts with all customers? 3. Within the past year, have the provisions in your standard contracts with customers changed? If yes, please attach a copy of your current standard contracts with customers. 4. Within the past year, have you negotiated contracts with customers where you accept liability for consequential damages? If, please explain when and how often: 5. Within the past year, have there been any changes in your systems development methodology or quality control procedures? TECH006 (02-13) Page 3 of 5

4 PART III: COMMUNICATION AND MEDIA LIABILITY COVERAGE IMPORTANT NOTE: Communications and Media Liability Protection is provided on a claims-made and reported basis. Where legal and applicable, defence expenses are included within the limits of coverage. Please check all that apply for your current and projected business activities. Current % Within 2 years a) Access or Presence: Informational or advertising website for % % your business or the ability to send/receive s, transfer files or browse the Internet: b) Communications: Internet Service Providers, Access Service % % Providers, On-line Service Providers: c) Electronic Commerce: Ability to order, buy or sell products or % % services over the Internet, including advertising of others on your website for a fee: d) Collaboration: Private communication networks or any extranet % % activities including providing systems resources to others: e) Data Storage: Including digital asset management and digital % % rights management software and services: f) Hosting: Hosting services provided to third parties, including % % public bulletin boards or chatrooms: g) Security: Consulting, assessments, installation or maintenance: % % Target Market(s) Please describe: h) Website design, development or maintenance for others: Including the development of e-commerce solutions for others: % % i) Other, please describe: % % INTELLECTUAL PROPERTY PROCEDURES 1. Does your intellectual property procedures including the following: a. Obtain appropriate written permission to use material, images and/or content of others used by you or created by you? N/A b. Internal audit of each operating department to ensure that Intellectual Property rights are being properly secured and that due diligence procedures are being followed? N/A c. Obtain agreements with outside developers or consultants to include provisions granting you ownership of the Intellectual Property rights incorporated into any work that you provide or is done for you or on your behalf? N/A d. Require employees and independent contractors/subcontractors to sign a statement that they will not use previous employers or clients trade secrets or other Intellectual Property? N/A e. Obtain written permission of any website you link to or frame? N/A f. On websites you have designed or have responsibility for, do you have inclusion of disclaimers as to the content of others? N/A g. On websites you have designed or have responsibility for, do you review or monitor the content of those websites for possible infringement of Intellectual Property? N/A h. With respect to employees, independent contractors/subcontractors to ensure that they are not authorized to modify or publish corporate materials which have not been screened? N/A i. Obtain clearance from outside or in-house legal counsel before products and/or services are released? N/A j. Conduct a search to ensure that your products/services do not violate any Intellectual Property? N/A k. Do you have a formal written policy or procedures in place to address any infringement? N/A l. Do you incorporate any software or products designed by others into your designs? N/A If to above, do you always obtain a licence to do so? *te: If any of the above questions were answered N/A, not applicable, please provide an explanation below: TECH006 (02-13) Page 4 of 5

5 PART IV: NETWORK AND INFORMATION SECURITY LIABILITY IMPORTANT NOTE: Network and Information Security Liability is provided on a claims-made and reported basis. Where legal and applicable, defence expenses are included within the limits of coverage. 1. Have there been any material changes over the past year in the products or services you or any of your subsidiaries provide through your website or a private communication network? 2. Within the last year, have you collected and/or stored private or confidential information of others through your website or private communication network (such as: money and securities; intellectual property assets; employee information; credit card information; employee, customer or business partner information? If, please describe the type of information: 3. Within the last year, have you shared any customer information with outside parties (including subsidiaries or affiliates) or have you sold any customer information to outside parties (including subsidiaries or affiliates)? If, please describe such information and with whom you share it: 4. Please describe any changes made to your network security policy in the last twelve (12) months: 5. Is private, sensitive or confidential information of others stored on your server(s) or portable communications equipment encrypted? ADDITIONAL COMMENTS (Attach additional sheets if required) DECLARATIONS AND PRIVACY STATEMENT This Application is not a representation that coverage does or does not exist for a particular claim or loss, or type of claim or loss, under any insurance policy issued by TICC/SPFM Insurance Company. Whether coverage exists or does not exist for a particular claim or loss under such policy depends on the facts and circumstances involved in the claim or loss and all applicable policy wording. The undersigned is an authorized representative of the prospective Named Insured and certifies that reasonable inquiry has been made to obtain the answers to these questions. He or she certifies that the answers are true, correct and complete to the best of his/her knowledge and belief. Where information has been provided about an individual(s), the undersigned confirms he or she has consent to disclose that information. The undersigned acknowledges that without this consent and his or her confirmation of consent, TICC/SPFM Insurance Company would not be able to consider this Application or submission. It is agreed that we may collect information about individuals in the course of considering the Application and submission and if we issue a policy, we may collect personal information in the course of conducting our relationship with you. Such personal information will be processed for the purpose of underwriting your coverage, managing any policy issued, providing risk management advice and administering claims. We may pass such information on to our reinsurers, legal advisors, loss adjusters or agents for these and other purposes associated with the insuring agreement. Signing this Application shall not constitute a binder or obligate TICC/SPFM Insurance Company to provide Technology Errors and Omissions Liability Protection or Communications and Media Liability or Network and Information Security Liability but it is agreed that this Application shall be the basis upon which a Policy may be issued. All information provided in this Application forms part of any policy effected pursuant to completion of such section. Applicant s Signature Title Date Broker/Agent Signature City Date TECH006 (02-13) Page 5 of 5